=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558758466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOMAL J PATEL PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2015
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3345 S DALE MABRY HWY
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33629-7817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-234-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5228 FALLEN LEAF DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33578-4740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-560-0756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 085.005429
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9109395
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------